Variation in Guideline Concordant Active Surveillance Followup in Diverse Urology Practices.
Luckenbaugh Amy N,Auffenberg Gregory B,Hawken Scott R,Dhir Apoorv,Linsell Susan,Kaul Sanjeev,Miller David C,
The Journal of urology
PURPOSE:We examined the frequency of followup prostate specific antigen testing and prostate biopsy among men treated with active surveillance in the academic and community urology practices comprising MUSIC (Michigan Urological Surgery Improvement Collaborative). MATERIALS AND METHODS:MUSIC is a consortium of 42 practices that maintains a prospective clinical registry with validated clinical data on all patients diagnosed with prostate cancer at participating sites. We identified all patients in MUSIC practices who entered active surveillance and had at least 2 years of continuous followup. After determining the frequency of repeat prostate specific antigen testing and prostate biopsy, we calculated rates of concordance with NCCN Guidelines® recommendations (ie at least 3 prostate specific antigen tests and 1 surveillance biopsy) collaborative-wide and across individual practices. RESULTS:We identified 513 patients who entered active surveillance from January 2012 through September 2013 and had at least 2 years of followup. Among the 431 men (84%) who remained on active surveillance for 2 years 132 (30.6%) underwent followup surveillance testing at a frequency that was concordant with NCCN® (National Comprehensive Cancer Network®) recommendations. At the practice level, the median rate of guideline concordant followup was 26.5% (range 10% to 67.5%, p <0.001). Among patients with discordant followup, the absence of followup biopsy was common and not significantly different across practices (median rate 82.0%, p = 0.35). CONCLUSIONS:Among diverse community and academic practices in Michigan, there is wide variation in the proportion of men on active surveillance who meet guideline recommendations for followup prostate specific antigen testing and repeat biopsy. These data highlight the need for standardized active surveillance pathways that emphasize the role of repeat surveillance biopsies.
Collaborative quality improvement.
Luckenbaugh Amy N,Miller David C,Ghani Khurshid R
Current opinion in urology
PURPOSE OF REVIEW:Quality improvement collaboratives were developed in many medical and surgical disciplines with the goal of measuring and improving the quality of care provided to patients. The aim of this review is to provide an overview of surgical quality improvement collaboratives, and in particular those aimed at improving urological care. RECENT FINDINGS:Quality improvement collaboratives collect high-quality data using standardized methodologies, and use the data to provide feedback to physicians and practices, and then implement processes to improve patient outcomes. The largest regional collaborative in urology is the Michigan Urological Surgery Improvement Collaborative (MUSIC). Recent efforts by this group have been focused at understanding variation in care, improving patient selection for treatment, reducing treatment morbidity and measuring and optimizing technical skill. The American Urological Association has also recently launched a national quality registry (AQUA), with an initial focus on prostate cancer care. SUMMARY:By understanding factors that result in exemplary performance, quality improvement collaboratives are able to develop best practices around areas of care with high variation that have the potential to improve outcomes and reduce costs. These developments have been made possible by the unique model offered by the collaborative structure with the goal of improving patient care at a population level.
The "Rule of W" in Urology: Testing Surgical Dictum.
Herforth Christine,Rocco Nicholas,Christman Matthew
OBJECTIVE:To evaluate the timing and frequency of postoperative occurrences as described in the "Rule of W" mnemonic for modern urologic and general surgical cases. METHODS:Using data from the American College of Surgeons National Surgical Quality Improvement Program, patients who underwent a urologic or general surgery procedure and developed a postoperative pneumonia (PNA), urinary tract infection (UTI), surgical site infection, venous thromboembolic event, or myocardial infarction (MI) were included. Frequency and median days to complication were compared. RESULTS:A total of 445,639 general surgery and 57,963 urology patients were included. Median time to occurrence differed between the cohorts for PNA, UTI, superficial infection, organ space infection, and MI. MI occurred earliest on POD3 for both groups (P = .0438). PNA occurred second on POD4 and POD5 for general surgery and urology, respectively (P = .0034). Venous thromboembolic events occurred third with PE occurring on POD8 for both cohorts (P = .1225) and deep venous thrombosis occurring on POD10 and POD11 (P = .6879) for general surgery and urology, respectively. Wound-related complications occurred at days 9-12 for general surgery and 11-13 for urology. The final sequence yielded waves, wind, walking, water/wound for general surgery and waves, wind, walking, wound, water for urology. CONCLUSION:A different chronology of postoperative events was found for urology patients than that described in the original mnemonic. UTIs and wound-related complications represent the most frequent morbidities for the urologic and general surgical patient, respectively. As patient demographics and practice patterns evolve, the "Rule of W", and other teaching tools, will need to be continually and critically reviewed.
Robotic Instrument Failure-A Critical Analysis of Cause and Quality Improvement Strategies.
Tapper Alexander,Leale Derek,Megahan Gregory,Nacker Kimberly,Killinger Kim,Hafron Jason
OBJECTIVE:To introduce a quality improvement initiative tracking robotic instrument failures on a per case basis. It is imperative to understand rates of failure, financial implications of failures, and identify factors suggesting common mechanisms of failure. MATERIALS AND METHODS:Starting in January 1, 2014 a quality reporting system for failed robotic equipment began. Staff was instructed to submit an incident report when a robotic instrument failed and the instrument returned to central processing. Instruments were then returned to the manufacturer (Intuitive Surgical Inc, Sunnyvale, CA) for analysis and reimbursement. Results of failure analysis by the manufacturer, including reimbursement rates, were recorded and correlated with the procedure and surgical specialty. RESULTS:A total of 3935 robotic cases were performed during the study period with a reported instrument failure incidence of 6.2% (247 total instruments). Etiology of instrument failure was as follows: tip or wrist (46.9%), cable (30.0%), unknown (12.6%), control housing (5.3%), and shaft (3.2%). Highest instrument failure incidence was seen in colorectal surgery cases at 4.0%, Urology had the lowest at 2.7%. Manufacturer reimbursement rate was 57.9%; the most common reason for denial being mishandling/misuse of equipment, determined by manufacturer analysis. CONCLUSION:Herein, we have demonstrated that improved process flow of reporting is necessary to better track incidence and etiology of instrument failures. Cost savings comes from improved training of not only surgeons but operating room and central processing staff in handling equipment to prevent high rates of reimbursement denial.
Improving Estimates of Perioperative Morbidity After Radical Cystectomy Using the European Association of Urology Quality Criteria for Standardized Reporting and Introducing the Comprehensive Complication Index.
Vetterlein Malte W,Klemm Jakob,Gild Philipp,Bradtke Marlon,Soave Armin,Dahlem Roland,Fisch Margit,Rink Michael
BACKGROUND:No procedure-specific definitions in complication reporting have been universally accepted in urological surgery, and conventional classification systems do not reflect cumulative morbidity. OBJECTIVE:To conduct a rigorous assessment of 30-d complications after radical cystectomy and improve morbidity estimates by introducing the novel Comprehensive Complication Index (CCI). DESIGN, SETTING, AND PARTICIPANTS:A retrospective proof-of-concept study of 506 patients with bladder cancer between 2009 and 2017. INTERVENTION:Radical cystectomy with pelvic lymph node dissection. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES:Thirty-day complications were extracted from digital charts based on a procedure-specific catalog. Each complication was graded by the Clavien-Dindo classification (CDC), and each individual CCI was calculated. We evaluated traditional morbidity endpoints and tested the ability of both classification tools to mirror cumulative morbidity. Multivariable regression analyses were employed for risk modeling using conventional and novel endpoints. The study fulfilled all the European Association of Urology (EAU) criteria of standardized reporting. Limitations include restricted follow-up of 30 d. RESULTS AND LIMITATIONS:Of 506 patients, 503 (99%) experienced a total of 2485 complications, of which the majority was classified as "minor" (CDC grade ≤ IIIa; 89%). Overall, 29 (5.7%), 20 (4.0%), and 12 (2.4%) patients were reoperated, readmitted, and died within 30 d, respectively. When using the CCI to capture cumulative morbidity, the proportion of patients with most severe complication burden (CDC grade ≥ IIIb or corresponding CCI > 33.7) increased to 31% as compared with 11% when considering only the highest-grade complication according to the CDC. Age-adjusted comorbidity and delta hemoglobin were the main drivers of perioperative complications for all outcomes in multivariable models. CONCLUSIONS:The assessment of short-term morbidity after radical cystectomy may be refined and optimized by employing the EAU criteria of standardized reporting and using the CCI to capture cumulative morbidity. These are the cornerstones of urgently needed procedure-tailored benchmarking to improve comparability and quality control. PATIENT SUMMARY:Characterization of short-term morbidity after radical cystectomy was improved by using several validated assessment tools and adhering to existing guidelines for reporting surgical complications.
Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme.
Gray William K,Day Jamie,Briggs Tim W R,Harrison Simon
Journal of evaluation in clinical practice
RATIONALE, AIMS, AND OBJECTIVES:The Getting It Right First Time programme aims to reduce variation in clinical practice that unduly impacts on outcomes for patients in the National Health Service (NHS) in England; often termed "unwarranted variation." However, there is no "gold standard" method for detecting unwarranted variation. The aim of this study was to describe a method to allow such variation in recorded practice or patient outcomes between NHS trusts to be detected using data over multiple time periods. By looking at variation over time, it was hoped that patterns that could be missed by looking at data at a single time point, or averaged over a longer time period, could be identified. METHODS:This was a retrospective time-series analysis of observational administrative data. Data were extracted from the Hospital Episodes Statistics database for two exemplar aspects of clinical practice within the field of urology: (a) use of ureteric stents on first emergency admission to treat urinary tract stones and (b) waiting times for definitive surgery for urinary retention. Data were categorized into 3-month time periods and three rules were used to detect unwarranted variation in the outcome metric relative to the national average: (a) two of any three consecutive values greater than two standard deviations above the mean, (b) four of any five consecutive values greater than one standard deviation above the mean, and (c) eight consecutive values above the mean. RESULTS:For the urinary tract stones dataset, 24 trusts were identified as having unwarranted variation in the outcomes using funnel plots and 23 trusts using the time-series method. For the urinary retention data, 18 trusted were identified as having unwarranted variation in the outcomes using funnel plots and 22 trusts using the time-series method. CONCLUSIONS:The time-series method may complement other methods to help identify unwarranted variation.
Urology Resident Involvement in Patient Safety and Quality Improvement Activities.
Van Leeuwen Bryant,Jinfeng Jiang,Deibert Christopher M
Current urology reports
PURPOSE OF REVIEW:To assess current urology resident engagement in patient safety and quality improvement (PSQI) and how to improve resident involvement in PSQI. RECENT FINDINGS:Overall urology resident participation in PSQI is low, especially when compared to other non-surgical residency programs. Multiple methods have been successfully implemented to increase resident participation in PSQI. Patient safety and quality improvement are extremely important to the progression of both urology and the healthcare community. True and meaningful participation in PSQI is lacking for many urology residents. However, there are easily adopted methods to improve resident involvement in this area of healthcare. These methods include direct communication and access between residents and hospital PSQI boards, resident-led safety councils, monetary incentives, formal training, and PSQI resident support teams.
Robot set-up time in urologic surgery: an opportunity for quality improvement.
Kozminski David J,Cerf Matthieu J,Feustel Paul J,Kogan Barry A
Journal of robotic surgery
INTRODUCTION:Robotic-assisted techniques are widespread in urology. However, prolonged preparation time for robotic cases hinders operating room (OR) efficiency and frustrates robotic surgeons. Pre-operative times are an opportunity for quality improvement (QI) and enhancing OR throughput. We have previously shown that pre-operative times in robotic cases are highly variable and that increasing patient complexity was associated with longer times. Our objective was to characterize set-up times in robotic urology cases and to determine whether prolongation was due to robot set-up, in particular. MATERIALS AND METHODS:Patients undergoing robotic-assisted urology procedures at our academic institution had routine peri-operative collection of demographic data and OR time stamps. Following IRB approval, we retrospectively reviewed set-up times from an OR database. Multivariable analysis was used to assess the influence of independent patient variables-gender (M/F), smoking history, age, BMI, American Society of Anesthesiologists (ASA) Physical Status Classification, and Charlson Comorbidity Index (CCI)-on robot set-up times. Institutional factors including procedure, surgeon, and case year were also assessed. RESULTS:A total of 808 patients undergoing 816 robotic-assisted procedures from 2013 to 2018 met inclusion criteria. Robot set-up times varied only by gender (F > M) but not by general patient complexity. Age, BMI, smoking status, ASA, and CCI did not play a role in prolonging robot set-up times. There was marked variability of robot set-up times, even within procedure type. Robot set-up times generally improved over time for a given surgeon. CONCLUSIONS:Robot set-up time is not affected by patient complexity, in contrast to pre-operative time. It is affected by procedure type and does improve with experience. There is wide variability of robot set-up times and this is an important target for surgical QI.
Implementation of a Ureteric Colic Telemedicine Service: A Mixed Methods Quality Improvement Study.
Ong Chloe Shu Hui,Lu Jirong,Tan Yi Quan,Tan Lincoln Guan Lim,Tiong Ho Yee
OBJECTIVE:To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments. METHODS:A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians. RESULTS:Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service. CONCLUSION:The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic.
National implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of 'theory-of-change' methodology.
Balayah Zuhur,Khadjesari Zarnie,Keohane Aoife,To Wilson,Green James S A,Sevdalis Nick
American journal of surgery
BACKGROUND:There is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the 'Education in Quality Improvement' program (EQUIP) in UK urology residencies. MATERIALS & METHODS:Theory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation 'Logic Model' in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis. RESULTS:Core elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents' QI projects). CONCLUSIONS:ToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.
Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative.
Johnson Kyle,Lane Brian R,Weizer Alon Z,Herrel Lindsey A,Rogers Craig G,Qi Ji,Johnson Anna M,Seifman Brian D,Sarle Richard C,
OBJECTIVES:To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient. METHODS:We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients. RESULTS:Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87). CONCLUSIONS:Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN.
Serious incidents in testicular torsion management in England, 2007-2019: Optimising individual and training factors are the key to improved outcomes.
Menzies-Wilson Richard,Folkard Samuel Stephen,Sevdalis Nick,Green James
OBJECTIVES:To establish the healthcare factors that contribute to testicular torsion adverse events (orchidectomies) and near misses. Our secondary objective was to identify areas suitable for impactful quality improvement initiatives to be undertaken by NHS healthcare providers nationally. MATERIALS AND METHODS:This was a retrospective record review and analysis, carried out in 4 phases. We applied the well-validated London Protocol patient safety incident analysis framework to all eligible serious incidents related to testicular torsion submitted by English NHS Trusts over a 12 year period to the Strategic Executive Information System' (StEIS) database. Clinical reviewers established the incident population (Phase-1); were trained and piloted the feasibility of using the London Protocol (Phase-2); applied the Protocol and themed the identified contributing factors linked to adverse events (orchidectomies) and near-misses (Phase-3); and reviewed the evidence for improvement interventions (Phase-4). RESULTS:Our search returned 992 serious incidents, of which 732 were eligible for study inclusion and analysis. Of those, 137 resulted in orchidectomies, equivalent to one serious incident resulting in orchidectomy per month, and 595 were 'near misses'. Factors contributing to all incidents were: Individual staff/Training (38%); Team (18%); Work Environment (16%); Task & technology (14%); Institutional Context (13%). Subgroup analysis of incidents resulting in orchidectomies vs. near misses demonstrated different pattern of factors, with individual staff/training factors significantly more prominent: Individual/Training (88%); Work Environment (8%); Task & technology (1%). No evidenced improvement interventions were found in the evidence-base. CONCLUSION:This is the first study to our knowledge to systematically analyse and classify factors that are associated with loss of a testicle and related near miss incidents in patients presenting with testicular torsion. In England there are a significant number of orchidectomies occurring annually as a consequence of healthcare serious incidents. In order to improve outcomes, we propose clinical support to aid the diagnosis of torsion, improved national clinical guidelines, development of specific standard operating procedures and (in the longer-term) more exposure of trainees and medical students to urology to improve testicular salvage rate.
Intraoperative Adverse Incident Classification (EAUiaiC) by the European Association of Urology ad hoc Complications Guidelines Panel.
Biyani Chandra Shekhar,Pecanka Jakub,Rouprêt Morgan,Jensen Jørgen Bjerggaard,Mitropoulos Dionysios
BACKGROUND:A surgical adverse incident (AI) is defined as any deviation from the normal operative course. Current complication-grading systems mostly focus on postoperative events. OBJECTIVE:To propose an intraoperative AI classification (EAUiaiC) to facilitate reporting. DESIGN, SETTING, AND PARTICIPANTS:The classification was developed using a modified Delphi process in which experts answered two rounds of survey questionnaires organised by the European Association of Urology ad hoc Complications Guidelines Panel. Experts evaluated AI terminology using a 5-point Likert scale for clarity, exhaustiveness, hierarchical order, mutual exclusivity, clinical utility, and quality improvement. OUTCOME MEASURES AND STATISTICAL ANALYSIS:We considered ≥70% agreement for inclusion or exclusion. The resultant EAUiaiC was evaluated using ten sample clinical scenarios. Numerical and graphical statistical techniques were used to report the results. RESULTS AND LIMITATIONS:In total, 343 respondents participated. The proposed EAUiaiC system comprises eight AI grades ranging from grade 0 (no deviation and no consequence to the patient) to grade 5B (wrong surgery site or intraoperative death). In the validation stage, EAUiaiC was rated highly favourably in terms of relevance and reliability (consistency) by 126 experts. Ratings for self-reported ease of use were at acceptable levels. CONCLUSIONS:We propose a novel intraoperative AI classification (EAUiaiC) for use for urological procedures. Both the initial assessment of feasibility and the subsequent assessment of reliability suggest that it is a simple and effective tool for classifying intraoperative complications. PATIENT SUMMARY:Complications in surgery are common. It is helpful to classify complications in a uniform and objective manner so that surgeons can easily compare outcomes and learn from complications. Here we propose a new classification system for complications that occur during urological surgical procedures. An abstract of this work was presented at the 2018 congress of the European Association of Urology.